The Rise and Fall of Modern Medicine (54 page)

‘The line is advancing', and the verdict in ‘Technology's Failings' of technology being ‘out of control' needs revising. The three illustrative examples of ‘The Misuse of Diagnostic Technology', ‘Foetal Monitoring' and ‘Technology and the High Cost of Dying' might be in their different ways undesirable – but they now seem more a regrettable consequence of, rather than intrinsic to, technology's potential to alleviate the problems of disease. That verdict also conceals how technical developments such as keyhole surgery have ‘democratised' medical interventions by
making them available to the ever greater number of those who might benefit from them. Much of surgery, for example, is essentially an exercise in applied engineering, constrained only by the vulnerability of the (ageing) tissues and organs of the body to the trauma of the procedures involved. Change that, make those procedures simpler or less traumatic, then the numbers for whom such interventions are deemed appropriate will rise remorselessly. It would seem appropriate to consider in rather more detail the three major developments that have allowed doctors ‘to do so much more'. They are coronary angioplasty (the dilation of narrowed blood vessels to the heart), minimally invasive (or keyhole) surgery, and the dramatic shift towards performing major surgery in those in their eighties and beyond.

The circulation of the blood, as first demonstrated by William Harvey in 1626, remains the unifying principle of physiology. Compromise that circulation by narrowing or blocking an artery, then whatever organ it serves, particularly the heart or brain, will be relatively (or absolutely) deprived of the life-sustaining oxygen carried in the blood – with the predictably adverse consequences of a heart attack or stroke.

It is, of course, possible to restore the circulation to the heart with a Coronary Artery Bypass Graft but it would be so much less intrusive and more elegant to do so ‘internally' by introducing, for example, a wire or catheter into the artery so as to dilate the obstruction from within, ‘like a footprint in the snow'. The origin of this most potent form of medical technology begins back in 1964, when an 82-year-old woman, Laura Shaw, was admitted to the University of Oregon Hospital with
a non-healing ulcer and gangrenous toes of the left foot due to a blockage of the major femoral artery in her leg. Her physicians advised that, in view of her age, her best option would be to have the leg amputated – which she steadfastly refused. The Professor of Radiology at the hospital, Charles Dotter, a self-confessed ‘inveterate doer and fiddler', suggested instead that the narrowed segment of the artery might be dilated in the manner just outlined. This was duly carried out, causing her cold pale limb to become once more warm and functional. Over the next few weeks the ulcer and gangrenous toes healed – and remained so till her death from pneumonia two and a half years later.
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This type of procedure is now so commonplace as to verge on the banal, but when Charles Dotter described its wider possibilities to a medical conference, anticipating its many subsequent applications, he received a standing ovation. ‘For those of us in the audience', as one of those present subsequently noted, ‘it was like a bomb had been dropped.'
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The blood supply to the heart, the coronary arteries, are a rather different proposition. The prospect of restoring the circulation ‘from within' is not only technically much more complex but would reasonably be interpreted as asking for trouble as the introduction of a wire or catheter carries the risk of critically reducing the already compromised blood supply to the heart, to cause precisely the problem that it is intended to prevent. Further, it would require a complete redesign of Charles Dotter's original catheter to create a balloon at the end capable, when dilated, of exerting sufficient force against the wall of the artery to dilate the obstruction. To this end a German cardiologist, Andreas Gruentzig, transformed his kitchen into a small laboratory where, with the help of his wife, he would fashion numerous versions of the balloon catheter with tiny bits of rubber, thread and epoxy glue.

First time round, he was unable to manoeuvre the catheter into the narrowed artery, following which his patient had a further major and lethal heart attack. His medical colleagues were not impressed and a further year would elapse before his second attempt, on a 38-year-old insurance salesman crippled by severe angina due to a single obstruction of his main left coronary artery.

On 16 September 1977, Gruentzig recalled:

Andreas Gruentzig, with this single manoeuvre, substituted the procedure of a standard coronary artery bypass graft – with its requirement to split the chest open to gain access to the heart, link it up to ‘the pump', and harvest veins from the legs to bypass the obstruction, followed by a lengthy convalescence – with another, the coronary angioplasty that can be performed under local anaesthetic, permitting the patient to be discharged from hospital the following day.
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This led in turn to the logical, if yet more audacious, proposal of further deploying coronary angioplasty not just to dilate narrowed arteries but as an emergency procedure in the early stages of an acute heart attack, to prevent damage to the heart muscle with its potentially lethal consequences. The rationale is simple enough: theoretically it should be possible to ‘recanalise' a
coronary artery blocked by a clot or thrombus, thus restoring the blood flow before it has caused too much damage to the heart muscle.
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But the logistical problems are (as can be imagined) considerable, for the procedure must be performed within half an hour of the onset of symptoms to have any chance of success. This requires a ‘system' of transferring the patient to a specialised unit continuously staffed by doctors with the requisite skills, able to respond rapidly if and when (as is inevitable with such a potentially high-risk venture) ‘things go wrong'. The practicalities of combining the necessary speed with the appropriate skill, competence and back-up are prodigious – but perhaps epitomise the success (indeed triumph) of modern medicine in their ability to ‘routinise' life-saving procedures in the most potentially dangerous of circumstances.

Thirty years on, cardiologists in the United States now perform a million coronary angioplasties every year, which have become technically ever more sophisticated with the insertion of ‘stents' coated with chemicals to prevent the artery from becoming narrowed again. The significance of this type of procedure in permitting doctors to ‘do more' is captured in a single statistic. Over the past decade, the number of coronary angioplasties in those aged eighty or more has increased twelve-fold.
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The techniques of keyhole or minimally invasive surgery rank as the single most radical development in surgery since the introduction of anaesthesia in the nineteenth century. It all began, as will be recalled, with the imaginative genius of the English physicist Harold Hopkins, who devised the sophisticated
optical systems of the fibreoptic endoscope and the laparoscope. Together, as set out in ‘Technology's Triumphs', these two ‘scopes' would transform the practice of modern medicine, where procedures that previously required a major operation are now performed routinely through the narrow steel tube of the laparoscope: for abdominal surgery – removing gall bladders, resecting the colon, repairing hernias; for gynaecology – removing fibroids, performing hysterectomies, pelvic floor reconstruction, sterilisation and IVF; for urology – repairing the neck of the bladder, removing the prostate gland and diseased kidneys; and orthopaedics – arthroscopic surgery for damaged and arthritic joints and prolapsed discs; and much else besides. The ascendancy of keyhole surgery is the more impressive, for while these procedures are certainly ‘simpler' for the patient in minimising the trauma and allowing for a much more rapid recovery, they are technically vastly more complex than the methods they have replaced.

‘[Keyhole] surgery carries significant disadvantages,' writes Andreas Melzer of the University of Dundee.

Nonetheless the ascendancy of both fibreoptic and laparoscopic surgery over the past twenty-five years is immensely
impressive. In Britain, they now account for four of the ten most frequently performed surgical procedures, where over the past two decades, the number of arthroscopies has gone up eight-fold (up from 15,000 to 117,000), while the number of endoscopic operations on the bladder has doubled from 123,000 to 289,000.
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Many of these procedures are relatively straightforward – such as inspecting the internal lining of the gut or bladder to identify a source of bleeding. But the implications for ‘advancing the line' are illustrated by the astonishing technical feat – first performed in 1990 – of removing the colon (the laparoscopic colectomy) in those with cancer or inflammatory conditions such as diverticulitis. Many of those requiring these operations are elderly and debilitated by other chronic illnesses, thus the keyhole approach has an obvious appeal. The technical complexities, as can be imagined, are daunting: not just cutting out the diseased segment of the bowel, but stapling the two free ends back together again, not to mention ensuring that vulnerable structures in close proximity such as the ureters draining urine from the kidneys to the bladder are not damaged. These problems are compounded for those with cancer by the need to ensure that the tumour is removed in its entirety, along with any lymph nodes to which it may have spread.
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Yet ten years on surgeons could report the average hospital stay for this procedure in those over the age of eighty had fallen to a mere two and a half days – with full resumption of normal bowel function. And, contrary to the previous misgivings that the keyhole approach would compromise the survival prospects of those with cancer, subsequent experience has revealed no difference in local or distant recurrence when compared with ‘open' surgery.
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Nor has this drive towards less pain, minimal scarring, fewer
complications and faster recovery reached its limits. Professor of Surgery at Washington University Richard Sataba insists rather that laparoscopic surgery is still ‘a transitional technology': ‘Its instruments remain awkward, bulky, imprecise, limited in performance by the direct forces applied by the surgeon's hand and arm.' These limitations, he anticipates, will be overcome by ‘intelligent' instruments that are ‘more precise and dextrous', thus extending the surgeon's skills ‘beyond the physical limits of human performance'.
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Notwithstanding the technical virtuosity of coronary angioplasty and keyhole surgery, the most significant impetus behind the medical expansionism of the recent past has been a major psychological shift in perspective – the increasing recognition by doctors and the public there are no longer, in principle, any age limitations to surgical intervention.

The origins of this dramatic shift can be traced to the publication in 1993 of an article in the prestigious
New England Journal of Medicine
under the heading ‘Too Old for What?'
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This ‘exercise in clinical problem-solving' concerned an ‘independent and active' 87-year-old woman with no known heart or pulmonary problems who consulted her physician with increased breathlessness. This, it transpired, was due to a combination of a tight narrowing of the aortic valve (aortic stenosis) together with severe narrowing of the coronary arteries – that on the left being completely blocked and with a 90 per cent narrowing on the right. It was, in short, astonishing she was still alive. There was no alternative – if something was to be done – other than to perform open heart surgery to both replace her aortic valve
and also bypass those obstructed coronary arteries. This was duly carried out, following which she developed kidney failure, the rapid irregular pulse of atrial fibrillation, wildly fluctuating blood pressure, congestive heart failure and depression. Five months later, she was back home and ‘had resumed an active social schedule' with, it was pointed out, a further life expectancy of at least five years – for most of which she could anticipate being ‘without cognitive or physical impairment'. So while there are obviously substantial risks associated with heroic surgery at this age, ‘notably, those who do survive are likely to live as long as their healthy peers'. Thus, a person's age might be ‘an important piece of information', but ‘the patient and doctor together must decide what is “too old”'.